This newest case of apparent death through neglect and malpractice came to my attention by way of Penny Richards at the Disability Studies blog, in “Yes, it can happen. It does happen.”
Penny has some good comments on the death of Linda Sue Brown, and I urge interested people to read them.
But you also need to read the full account of the death of Linda Sue Brown, available at the LA Times (free registration required for access) in a story titled “Two nurses lose sister, find their faith in medical system shaken.”
For 50 years Linda Sue Brown’s nine siblings fiercely protected her, facing down anyone who would taunt her or seek to exploit the disability that left her with the mental capacity of a 12-year-old.
That sense of responsibility only grew after their 81-year-old mother, Brown’s lifelong caretaker, was stricken with Alzheimer’s disease, leaving her unable to tend to her daughter. So when Brown’s lower legs swelled last summer and she grew short of breath, her eldest sister rushed her to a place the family knew and trusted: Brotman Medical Center in Culver City. One of Brown’s sisters, Thelma Allen, worked there as a nurse; another, Rosslyn Diamond, had previously been a nurse there. And Brown had been treated there, successfully, for years.
At the 420-bed hospital, tests revealed that Brown had an enlarged heart, fluid in her lungs and severe anemia, medical records show. She received blood transfusions and, two days later, an emergency hysterectomy. Afterward, Allen was given an unorthodox, but welcome, assignment: She was to be one of Brown’s nurses.
On July 4, after her shift ended, Allen watched TV with Brown, then kissed her good night.
By the time she returned the next morning, her sister was dead.
The death was probably caused by a pulmonary embolism, a clot of blood blocking an artery to the lungs, Diamond recalled the surgeon saying. If so, nothing could have saved her.
For most grief-stricken relatives, the questions would have ended here. Patients die unexpectedly in hospitals every day. If families have vague doubts about why and how, they typically lack the knowledge and access to get answers.
But Diamond, 60, and Allen, 59, vowed to find out what happened to their sister.
Along the way, they discovered that their decades of experience afforded them little advantage over any other bereaved family. Instead, almost everything they believed about the medical profession was turned on end. And ultimately, the answers they battled to get have provided little comfort.
After months of investigation, state health inspectors determined that Brown’s death was nothing so random as an embolism.
Brotman staffers, the inspectors found, had failed Brown in virtually every way: Her nurses — Allen’s colleagues — appear to have forged consent forms and had Brown sign agreements that she couldn’t understand. One failed to call for help as Brown’s vital signs plummeted.
Her doctors didn’t investigate signs of heart failure, performed a risky emergency surgery with no clear justification and then didn’t intervene as her condition deteriorated. And hospital officials didn’t even look into what went wrong until inspectors inquired.
There’s plenty more in this long investigative article.
Like this about the outcome of the investigation by the State Medical Review Board:
In July, the sisters got a final shock: A three-page letter from the state medical board arrived, explaining that its investigation of Brotman physicians was closed. Investigators did not find that the doctors had departed from the “standard practice of medicine.”
Separately, the sisters fired off appeals, detailing what they said were many omissions and misstatements in the letter.
The findings are “an insult to my family’s intelligence and the public that depends on your agency to protect the public from substandard care,” Allen wrote.
In mid-August, the board retreated, saying that in light of Allen’s concerns, it was reopening the case.
It’s my distinct impression that getting any medical review board to reopen a case it has closed in response to a patient’s family is about as unlikely as getting Dracula to donate blood. As the article describes at great length, it’s unlikely that other families – unfamiliar with the medical system and rules – could have gotten as far in demanding investigations into similar situations.
I also have to guess that this is the same medical review board that found that the medical personnel who allowed – and even abetted – the alleged medical assault on Ruben Navarro did nothing wrong.
Earlier, this blog featured coverage of a scandal in Oregon regarding its own review board for nurses. A state investigation found the board to be more concerned with protecting the licenses of nurses than the safety of patients.
Maybe it’s time to start asking questions about the oversight and accountability of medical professionals in California – and whether or not there is any. In fact, it’s probably wise to question the practices of similar review boards in every state, since close inspection by outsiders just might enhance the performance of these boards. –Stephen Drake
